Nokea
A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?
- A. Notify the physician.
- B. Clamp the chest tube.
- C. Replace the system.
- D. Document the finding.
Correct Answer: D
Rationale: Gentle bubbling is a normal finding for the client who has a pleural drainage system to suction, so it simply needs to be documented. If the bubbling becomes vigorous, it could indicate a leak, which the nurse needs to investigate. The remaining choices are not necessary.
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Which of the following statements indicates adequate dietary understanding in a client with constipation?
- A. I should decrease my intake of fluids.
- B. I should decrease my level of activity.
- C. I should increase my intake of apples.
- D. I should increase my intake of milk.
Correct Answer: C
Rationale: Apples are a source of high fiber, which decreases constipation. A constipated client needs to increase fluids and activity level. Milk is not a high-fiber food.
A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct Answer: A
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak.
The role of the incident report in risk management is:
- A. liability protection.
- B. to provide data for analysis by a risk manager to determine how future problems can be avoided.
- C. to discipline staff for errors.
- D. all of the above.
Correct Answer: B
Rationale: Incident reports are a tool for determining how future problems can be avoided. Incident reports do not provide liability protection. Incident reports are not meant to be used for disciplining staff.
A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of?
- A. positive
- B. false positive
- C. negative
- D. false negative
Correct Answer: B
Rationale: A false positive occurs when a test incorrectly indicates a disease is present, potentially leading to unnecessary treatment or anxiety.
A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct Answer: D
Rationale: A client with cirrhosis is at risk for developing a high ammonia level.